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Medical Record #: 143098598-292984
Patient Identification #: 0284475-2384917-2835
Patient Name: Robert Callaghan
Patient Date of Birth: ##/##/19##
Date of Entry: ##/##/203#

Discharge Summary

Patient is a ## year old Caucasian male that arrived at San Fransokyo Memorial Hospital on ##/##/203# in severely critical condition following involvement in a fire with traumatic impact from falling debris. Fourth-degree and third-degree burns covered approximately 23-25% of his body primarily on the left side with additional second and first degree burns adjacent across an additional 10-12% of his body, primarily over the left lateral dorsal aspect of the trunk. Burns to his left lower and upper extremities had reached bone primarily in the hand and foot, but also resulted in exposure of the left distal ulna, left distal radius, and left tibia. In a brittle state secondary to extensive burns, the bones of the left lower and upper extremity showed numerous simple and compound fractures. Although immediately considered nonviable with little to no blood supply to distal left extremities, full amputations were delayed to address more immediate concerns. Multiple rib fractures were found in the thoracic region, including left ribs 2-6, 8-10 and 13, 15 and right ribs 2, 5, and 11. Secondary to these fractures, the patient was suffering from atelectasis of the both left lung lobes with a severe hemopneumothorax with the right lung presenting with diminished sounds. Non-displaced spinal fractures were found at T6, T9, and L1. Cervical region and cranium appeared clear of fractures upon both initial and later x-ray and CT scans, despite initial Glasgow Coma Scale scoring of 7. Mandibular fractures on the left were found with complete rupture of the left temporomandibular joint as well as destruction of the orbital left space with loss of the left eye. With oral entry difficult, a tracheotomy was performed in the ER to assist in stabilization of the patient with positive air pressure applied to slow the progression of the hemopneumothorax until able to transfer into surgery. Additional fractures of the left clavicle, left humerus, and left scapula were also noted but unable to be immediately addressed.

The patient was taken directly into surgery from ER to relieve the hemopneumothorax with a bilateral thoracotomy performed. Following draining from the chest cavity with placement of drains, further surgery was required at this time to address dual grade 1 liver lacerations, grade 3 splenic injury with expanding hematoma, and to amputate majority of nonviable tissues of the left extremities. Burn dressings were placed to provide barrier protection. Despite the extensive time required to complete the surgeries and multiple transfusions of blood products, the patient vitals remained generally stable and was transferred to ICU care.

With high risk of sepsis due to the estimated 33 to 37% surface burn trauma, the patient was immediately placed on broad-spectrum IV antibiotics. Within the first 24 hours of ICU care however, EKG abnormalities were reported with initially intermittent then sustained arrhythmias along with the onset of fevers reaching as high as 103.7 degrees F. With declining status in multiple areas including signs of heart failure, increasing respiratory support required, need for further blood transfusion, and decreasing circulation to injured areas it was decided that the patient would be placed on ECMO support. Cultures returned from the lab supported the diagnosis of sepsis and new antibiotics were initiated to bolster broad-spectrum treatment.

Fevers were reduced within the following two days, and the patient was returned to surgery for stabilization of fractures of the chest cavity with additional placement of the Lidwill Biatrial and Biventricular Cardiac Pacemaker and cardiac muscle shroud strips to reinforce contractility of the heart with appropriate rhythms. Additional debridement of necrotic tissues on the left extremities was performed at this time to reach viable tissue at the distal humerus and distal femur and negative pressure wound therapy was applied to increase blood flow.

Sedation protocols remained in place until the patient was successfully weaned from ECMO support 3 days later. Intravenous nourishment protocols were discontinued in favor of initiating NG tube feeding to improve protein supplementation. Sedation was then steadily reduced to allow patient to return to full consciousness with continuous morphine drip in place. Although still experiencing significant pain, the patient was able to communicate appropriately with various staff members intermittently and became oriented to situation, date, and place. Repeat CT-scans showed no neurological involvement at the head and no disruption to spinal fractures. Gradually the patient was weaned from ventilator support to BiPap then supplemental oxygen support over the course of 3 weeks. During this time, bedside dialysis was performed twice a week to reduce stress on his kidneys while wound care continued to treat the extensive burns with bedside debridements performed to reduce bioburden from necrotic tissues before final trunk closure in the OR on ##/##/203#.

From there, his care continued with coordination with additional teams for reconstruction and prosthetic application. It was decided that facial, optical, and trunk plating prosthetics would be preferred over long term reconstruction efforts with reduced recovery time and improved functionality. Additionally, it was also decided that prosthetic linking bases would be needed but the patient refused limb prosthetics. Upon further inquiry, it was noted that the patient intended to design new limbs for himself.

Over the subsequent 9 days, the patient was taken to surgery for prosthetic application beginning at the head and neck, moving to the trunk, then application to residual limbs. All prosthetic models applied can be found in the surgical appendix to this summary note.

The patient was then transitioned to medical care out of the ICU in the post-trauma unit, and there began acute physical therapy. Initial attempts to mobilize were limited by reduced tolerance for vestibular disturbances due to extended time spent in supine positioning, but he acclimated quickly. Occupational therapy and speech therapy were also initiated. Speech therapy was able to transition the patient from NG tube feeding to nectar thickened and chopped diet.

After monitoring the patient on the post-trauma unit for one final week, it was determined that his blood panel results were at a stable point and the patient was discharged to inpatient rehabilitation locally.

It has been my pleasure to be involved in this case from the beginning of his care to discharge from acute care services. I look forward to subsequent follow-up visits at my office following Mr. Callaghan' discharge from inpatient rehabilitation.

Signed,

Palmira Benitez, MD, MS, FAAEM

Appendix 1: Patient medical history
Appendix 2: Medications
Appendix 3: Surgical Interventions